Different experiences, different approach: trauma-informed care to address disparities and inequities

Trauma-informed care is a key tool for healthcare professionals to address the unique factors of individuals and ensure that treatment is provided in a way that meets each patient’s needs. A disparity exists where one can observe a difference in outcome between two groups. An inequity exists when a disparity is a result of the difference in some factor experienced by those groups. Although healthcare professionals are naturally oriented toward addressing specific health problems, trauma-informed care challenges us to realize and address the complex interactions between trauma from patients’ personal lives, their unique identities, society, history, and other sources. It is a tool that belongs in every patient interaction, regardless of their race, gender, sexuality, or other characteristics. It is through a consistent framework that we can identify a unique approach for each patient in order to recognize the inequities they may have experienced, respond in a manner appropriate to their needs, and resist anything that could result in retraumatization.

Trauma-informed care has five key principles central to eliminating inequities and disparities in treatment. The survivor’s environment must have safety established. If the survivor does not feel safe, they will not be able to experience optimal care.¹ The environment and those in it must also be characterized by predictability.² Surprises or unexpected changes can erode a survivor’s comfort. Third, providers must establish collaboration with the patient. If the patient does not experience some agency or control, the environment may more closely resemble the source of their trauma.¹ Awareness must be enhanced and the provider must assess the impact of the trauma on their patient.³ The scope of the trauma and other sources of the patient’s trauma must be investigated to provide treatment in an understanding way. Finally, one must have a self-awareness of stress and trauma reactions. As providers, we can be reminded of our own traumas or experience visceral reactions to trauma experienced by patients.¹ A physician re-experiencing trauma may reflexively change their attitudes or behaviors in a way that erodes the developing relationship with a patient. Each of these principles helps to produce trust with the patient. If trust is not gained, inequities cannot be addressed and disparities will remain.

For many people who experience trauma, a visit to a healthcare facility can be difficult. Doctors, nurses, and other care providers are often perceived as authorities, and many forms of trauma are the result of exploitation from a person in authority. Because of this common perception, providers must take the first step in developing a safe environment for communication and understanding.

Some people who experience trauma do not identify as victims of traumatic events. In these events, providers have the unique challenge of helping individuals identify the harm they experienced. Uncovering trauma is not an immediate process. Physicians and other providers may only have brief time frames with patients but helping them recognize their trauma is critical. Then, they can begin a path to recovery.

I recently attended a presentation from an ER physician on treating victims of sexual assault. They saw trauma-informed care as central to their oath as a physician to “Do no harm.” When a patient entered the ER, they had to anticipate a number of complicating factors to ensure optimal treatment and a path to recovery for their patient. Is the patient comfortable in a room with someone of the same gender as their assailant? How could you perform a physical examination in the least intrusive way possible? Is the patient willing to file a report with law enforcement and will they accept a sexual assault forensic examination (SAFE)? These are all complicating factors that may differ between patients. For some patients, this may be the most significant trauma of their life. For other patients, this could be the latest in a long line of traumas that lead them to respond in an unexpected way. Treatment providers are at risk of retraumatizing their patient from a variety of different actions if they do not proceed with care.¹

In the wake of the COVID-19 pandemic, trauma-informed care is key to ensuring optimal treatment for many groups, including African-Americans. US medical history is rife with exploitation of black individuals like Henrietta Lacks or those in the Tuskegee Syphilis Study. Trauma-informed care demands that providers understand the role that historical injustices play in the medical decision-making of patients. If a black individual declines a vaccination or treatment, one’s initial response may be incredulity. A trauma-informed care approach would seek to address the inequity that could result from black individuals declining treatment due to a recognition of historical exploitation of black people. In this scenario, a provider who recognizes these and other factors could ask the patient to explain their concerns about treatment. As another option, the provider could seek out black physicians who could provide another perspective for the patient to hear. Whether treatment is accepted or declined, creating space for dialogue can improve treatment adherence in the future.

Healthcare providers are the first line of treatment for most physical traumas, and they are often key to helping patients heal from emotional, psychological, social, and other forms of trauma. The experience of trauma is deeply personal and has different effects on each individual. This is why trauma-informed care is a framework with principles that allow for tailored approaches to each situation. Because each person experiences trauma in different capacities, the inequity they experience also varies. Trauma-informed care allows us to address healthcare inequities and disparities with a recognition of the unique makeup of every person.